If you have (or think you may have) bipolar disorder, or are coping with another type of mood disorder, this daily mood chart will allow you to record your highs and lows over the course of a month. There are also spots to keep track of other situations that may impact your emotions and moods.
Instructions for on the daily mood chart/log form
Mood rating: At the end of each day, rate your mood based on the “Highest” and “Lowest” that you felt that day. Place a dot in the box that best describes your mood, and if you had high and low moods on the same day, place two dots.
Anxiety & irritability: Rate each on a scale from 0-3 (0=low, 3=high) daily
Medications: Note any additional medications taken, medication dosage changes and any adverse effects attributed to medications with a “x” and describe more fully in the Mood Diary Explanation Log.
Alcohol/drugs: Place an A if you drank alcohol, or a D if you used any medications, drugs or remedies not prescribed by a doctor. (Use the back of the page or a separate sheet to elaborate if needed.)
Exercise: If you have a regular exercise routine, please add a Y for each day you exercise. Add an asterisk (*) next to the Y when you have exercised, but it is different than your normal routine. (Also note the intensity and duration of this exercise on the back of the page or on a separate sheet.)
Food intake: If you have not eaten regular meals and/or have eaten different amounts or types of foods, please note the differences on the Mood Diary Explanation Log, and use an asterisk (*) in the box.
Menses: Note the day that you start your period with a dot and note each subsequent day of bleeding until your period is over. (If you know the day that you are ovulating, please note this with an O, and otherwise leave blank.) If your period is shorter or longer or differs in the amount or duration of bleeding or associated symptoms, please note that on the back of the page or on a separate sheet.
Stressful/emotional event: Please note with an asterisk (*) any days that you have had an event, occurrence or interaction that was very stimulating (positive or negative). This may include physical or mental/emotional symptoms. For any day you note, please elaborate on the back of the page or on a separate sheet.